Clinical practice guidelines: Questions of relevance, reliability and utility explored

October 2018
Professor Ann Roche, Director, NCETA

Clinical practice guidelines are a key component of health care. They are increasingly important in the AOD sector, as in many other areas of health care. They are designed to provide evidence-based recommendations for health care professionals about the management of care for clients and patients with AOD problems.

But clinical guidelines are not without limitations, and they have been the subject of some debate and criticism in the past. However, a number of important developments have occurred in recent years to increase the reliability of, and our confidence in using, clinical guidelines.

The 2011 Institute of Medicine (IOM, now the National Academy of Medicine) report Clinical Practice Guidelines We Can Trust was an important game changer [1]. The IOM proposed methods for guideline development that set the bar considerably higher than had previously been the case. This was followed in 2012 by the internationally representative Guidelines International Network standards [2].

IOM rigorously redefined clinical practice guidelines as “statements that include recommendations, intended to optimize patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options [1].”

Of pivotal importance, these substantially tighter standards meant that practice recommendations that were not explicitly informed by a systematic review should no longer be considered a clinical practice guideline. In the US, this definitional change resulted in a reduction of nearly 50% in the number of guidelines listed on the National Guideline Clearinghouse (NGC), from 2619 in 2014 to 1440 in 2018 (as older guidelines without a systematic review were removed from that site).

New criteria were also established to ensure a guideline’s reliability that included: use of a multidisciplinary panel of experts, managing conflicts of interest, consideration of patient subgroups and patient preferences, using an explicit and transparent process for development, providing ratings of both the quality of the evidence and strength of the recommendations. In addition, other factors such as the use of non-stigmatising language is also flagged as an important quality criterion.

In Australia, the National Health and Medical Research Council [3] endorsed the Appraisal of Guidelines for Research and Evaluation (AGREE) [4] as an international tool to assist in the development and evaluation of guidelines, and the AGREE II Reporting Checklist created in 2016 [5]. At the time of writing, the NHMRC was working with an Expert Advisory Committee to develop a new online resource for guideline developers that would supersede its current Standards. This new resource will be published in self-contained modules on the NHMRC 'Guidelines for Guidelines' website and is scheduled to be launched in late 2018 [3].

In relation to drugs of concern such as methamphetamine, Australian clinical guidelines are of variable quality. The National Centre for Clinical Research on Emerging Drugs (NCCRED) recently commissioned the National Centre for Education and Training on Addiction (NCETA), Flinders University, to undertake an audit of Australian clinical guidelines for methamphetamine use disorder that were available to support clinical interventions. The results of the audit will be available in the near future. Hopefully, this will guide the use of guidelines overall, their application in practice, and the development of even more robust guidelines into the future.

1. Greenfield S, Steinberg EP, Auerbach A, Avorn J, Galvin R, Gibbons R. Clinical Practice Guidelines We Can Trust. Washington, DC: Institute of Medicine; 2011.

2. Qaseem A, Forland F, Macbeth F, Ollenschläger G, Phillips S, van der Wees P; Board of Trustees of the Guidelines International Network. Guidelines International Network: toward international standards for clinical practice guidelines. Ann Intern Med. 2012;156(7):525-531. doi:10.7326/0003-4819-156-7-201204030-00009

3. National Health and Medical Research Council. (2011). Procedures and requirements for meeting the 2011 NHMRC standard for clinical practice guidelines. Canberra: National Health and Medical Research Council.

4. Brouwers, M., Kho, M., Browman, G., Burgers, S., Cluzeau, F., Feder, G., . . . for the AGREE Next Steps Consortium. (2010). AGREE II: Advancing guideline development, reporting and evaluation in healthcare. Canadian Medical Association Journal, 182(18), E839-E842.

5. Brouwers, M., Kerkvliet, K., Spithoff, K., on behalf of the AGREE Next Steps Consortium. (2016). The AGREE Reporting Checklist: a tool to improve reporting of clinical practice guidelines. British Medical Journal, 352, i1152.